International Student Premiums Application

Coverage dates: January 7, 1980 to January 10, 1982

Quotes Accepted:

Applicant	Student Plan	Coverage	Deductable	Premium
1	Enhanced	$200,000	$10,000	$10,000.00
2	Enhanced	$200,000	$10,000	$10,000.00
3	Enhanced	$200,000	$10,000	$10,000.00
4	Enhanced	$200,000	$10,000	$10,000.00
5	Enhanced	$200,000	$10,000	$10,000.00

Minimum Adjustment Charges:

Total Premium:

Want to enroll in monthly payment option?

Monthly payment schedule:

Monthly installment: $500

Payment due today: $500 (2 months instalment + $50 one time fee)

Applicants Information

Applicant 1 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Applicant details*

Applicant 2 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Applicant details*

Applicant 3 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Applicant details*

Applicant 4 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Applicant details*

Applicant 5 (Birthdate: January 31, 2020)

Given Name(s) *

Last Name *

Gender *

Applicant details*

Beneficiary in case of death

Beneficiary name *

Relationship to insured *

Address *

City *

Country *

Travel Information

Country of origin: *

Destination province: *

Arrival date: *

Address in Canada

Street Adress: *

Street Address 2

City: *

Province: *

Postal Code: *

Home Phone: *

Work Phone

Email: *

Confirm Email: *

How would you like to pay? *

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Payment Details

Payment amount $500.00

Card type: * Visa Mastercard

Name on card: *

Card number: *

Card Expiry: *

Security code: *

Postal code: *

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